Provider Demographics
NPI:1275090094
Name:YODER, CONNER (RDN, LD)
Entity Type:Individual
Prefix:
First Name:CONNER
Middle Name:
Last Name:YODER
Suffix:
Gender:M
Credentials:RDN, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9804 ACACIA PSGE
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46835-9143
Mailing Address - Country:US
Mailing Address - Phone:260-479-0080
Mailing Address - Fax:
Practice Address - Street 1:9804 ACACIA PSGE
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46835-9143
Practice Address - Country:US
Practice Address - Phone:260-479-0080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-28
Last Update Date:2022-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH08691133V00000X
IN37002960A133VN1004X, 133VN1005X, 133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric
No133VN1005XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Renal